Student Emergency Form Elementary Honors Chorus Student Emergency Form I authorize my child's music teacher to grant consent for medical treatment in an emergency for my child in my absence on November 11 & 12, 2017 by submission of this form through mail and electronic submission. I assume all financial responsibility for medical cost over and above my insurance benefits.Music Teacher Name* First Last School Name*Student's Name* First Last Parent/Guardian's Name* First Last Relationship to Student*Cell Phone #*Aternate Phone #*Emergency Contact Name* First Last Phone #*Cell Phone #*Insurance Company*Policy Holder*Policy Number*Group Number*CAPTCHA